Provider Demographics
NPI:1508085168
Name:SHORES RHEUMATOLOGY PC
Entity Type:Organization
Organization Name:SHORES RHEUMATOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:A
Authorized Official - Last Name:BRENNAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-777-7577
Mailing Address - Street 1:24100 LITTLE MACK AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-3247
Mailing Address - Country:US
Mailing Address - Phone:586-777-7577
Mailing Address - Fax:586-777-6484
Practice Address - Street 1:24100 LITTLE MACK AVE
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-3247
Practice Address - Country:US
Practice Address - Phone:586-777-7577
Practice Address - Fax:586-777-6484
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MITB038759207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0E06260Medicare ID - Type Unspecified